AIM: To evaluate the effect of remimazolam on early postoperative cognitive function in elderly patients with hip fracture based on a randomized controlled trial. METHODS: A total of 106 elderly patients, aged 65-90 years, ASA grade Ⅱ or Ⅲ, who underwent hip fracture surgery under combined spinal-epidural anesthesia in the Sixth Affiliated Hospital of Wenzhou Medical University from December 2022 to June 2023 and met the inclusion criteria, were selected and randomized into remimazolam group (group R) and propofol group (group P) according to the random number table, with 53 cases in each group. Patients in group P received a slow intravenous injection of propofol at a dose of 0.3-0.5 mg/kg (injection time of 1min), followed by a pump infusion at 0.5-3 mg·kg-1·h-1 for maintenance. In group R, intraoperative sedation was maintained by remimazolam at 0.1-0.3 mg·kg-1·h-1 after a loading dose of 0.05 mg/kg (injection time of 1min). The pump infusion rate were adjusted by maintaining MOAA/S score at 3-4 and BIS value at 75-85, and stopped administering sedatives while suturing the incision. MOAA/S score, MAP, HR, RR, SpO2 and BIS values were recorded before sedation (T0), 5 (T1), 10 (T2), 15 (T3), 30 (T4) and 60 (T5) min after sedation and at the end of surgery. The emergence time, intraoperative amnesia, the incidence of postoperative delirium (POD) and delayed neurocognitive recovery (DNR) within 7 days after operation, and the occurrence of adverse events during perioperative observation were recorded. RESULTS: Compared with T0, the BIS and MOAA/S scores of the two groups at T1-T5 were significantly decreased, and the MAP and HR of the two groups at T1-T6 were significantly lower (P<0.05). Compared with group P, group R showed higher MAP at all time points from T1 to T6 (all P<0.05), shorter emergence time (6.6±1.8 vs. 7.7±2.2 min, P<0.05), less decline in Hopkins Verbal Learning Test scores on postoperative day 7 (3.9±3.9 vs. 6.2±4.6, P<0.05), lower incidence of postoperative delirium and DNR (7.5% vs. 28.3%，5.7% vs. 20.8%, P<0.05), higher incidence of intraoperative amnesia (52.8% vs. 28.3%, P<0.05) lower incidence of hypotension and bradycardia (15.1% vs. 37.7%, 5.6% vs. 22.6%, P<0.05), and fewer frequent use of vasoactive drugs (P<0.05). CONCLUSION: Application of remimazolam for perioperative sedation in elderly patients with hip fracture can provide effective sedation and stable hemodynamic, with little effect on early neurocognitive function, and overall safety higher than propofol.